How Many Anchors Are Used In Rotator Cuff Surgery

Review Article

Rotator gage repair: technical considerations influencing optimum anchor choice in rotator gage repair

Introduction

Suture ballast choice for arthroscopic rotator cuff repairs depends on multiple variables and situations. In that location are many anchors bachelor in the marketplace specifically canonical for rotator cuff repair. Nosotros are going to focus on how to determine on the best option when selecting a suture ballast while keeping in heed clinical considerations such every bit historic period, bone quality, tissue quality, re-tear risk, tear size, activity level, and patient expectations. It is too of import to appreciate surgeon preferences and feel with the different types of anchors. The common materials used in anchors include biodegradable (including biocomposite), polyetheretherketone (PEEK), suture based (all-suture anchors), and metal (usually Titanium). Most all of the recently developed anchors are made from non-metallic materials. The trend away from metal anchors is probably due to concerns about obscured post-surgical imaging, challenges associated with hereafter revision procedures or the need to remove metallic anchors, well-publicized radiographic images of metal anchor migration to intra-articular positions, and concerns about articular cartilage harm.

Biodegradable materials currently used for these devices belong principally to the family of poly lactic acid polymers. These polymers dethrone principally past hydrolysis without the enzymatic activity associated with poly glycolide polymers. The mechanical and physical backdrop of these polymers can be engineered in diverse means to impact the performance of the suture ballast. Suture ballast degradation characteristics depend on various parameters including molecular structure, whether the textile is more than amorphous or crystalline, and the ratio of the stereoisomers to any copolymer. The incidence of cyst formation and anchor failure related to this phenomenon is low. In a study by Cobaleda et al. the charge per unit of anchor-related adverse events was 0.5% without any reports of cyst formation or inflammatory reaction (i).

For a suture anchor to be considered "proficient" for rotator cuff tendon repair it must have the following characteristics: (I) deeply gear up the suture to the bone; (Two) not pull out of the bone during cyclic stresses; (III) be hands inserted; (4) facilitate arthroscopic knot tying; (5) hold multiple sutures; and (VI) not cause long term morbidity. Other desirable features include a simple associated set of insertion instruments, depression toll, and attentive industry support.

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Rotator cuff tissue

Rotator gage tears can be fractional thickness, longitudinal, or complete thickness. Consummate tears can be moderately retracted or significantly retracted. Failed repairs tin accept tears at the human foot print or at the musculotendinous junction. Each of these presents specific challenges and different anchor choices may exist considered.

Fractional thickness tears

Partial-thickness rotator cuff tears are mutual. In fractional tears, the tendon fibers are disrupted only no glenohumeral articulation to subacromial space communication exits. Clinically meaning partial-thickness rotator cuff tears are either bursal-sided tears (Monk's Hood) or partial articular supraspinatus tendon avulsions (PASTA) (Figure one). Intra-tendinous tears besides be but usually do non cause clinical symptoms. The articular-sided tears are more common and near involve the supraspinatus tendon (two). While PASTA tears predominate in the older patient population, Monk'due south Hood tears and intra-tendinous tears are seen in younger overhead athletes almost the supraspinatus-infraspinatus interval (3).

Figure one Partial articular supraspinatus tendon avulsions (PASTA) tears are partial thickness disruptions in which the rotator cuff tendon is torn from the articular surface. This posterior portal view of a left shoulder demonstrates the debrided footprint site on the greater tuberosity prior to repair.

Partial thickness tears exercise not heal and if clinically significant, surgical intervention is advisable. Fukuda et al. have shown that these tears have no ability to heal themselves (iv). Yamanaka et al. showed an lxxx% progression of fractional-thickness gage tears over ii years, with 28% converting to full thickness tears (five).

PASTA tears

The surgical technique is ordinarily planned preoperatively but the final approach should be adamant after an arthroscopic assessment including probing. This assessment should consider patient age, tear size, depth, and tear location. Additional problems such as biceps tendon pathology may also influence the specific technique used. Finally, surgeon experience is very important. PASTA tears involving 50% or more than of the tendon thickness at the footprint justify operative treatment. In patients less than xl years of age tears involving equally little equally 30% of the tendon thickness may justify surgical intervention. This is peculiarly true in acute traumatic tears, bursal-sided tears, and more than physically agile patients.

2 surgical techniques are used for PASTA tears: the trans-tendon repair and the release and repair arroyo. The trans-tendon repair is recommended for partial tears with tendon disruptions between l% and fourscore% and good quality in the remaining tendon tissue. Since the supraspinatus tendon is usually nearly 12 mm thick and the tendon edge starts about two mm from the articular cartilage, an articular surface footprint exposure of 8 mm would advise a 6 mm tendon tear or a fifty% supraspinatus tendon disruption. The trans-tendon PASTA repair starts with debridement of the greater tuberosity side by side to the articular cartilage. Once debridement is complete, anchor placement is performed.

Suture anchors appropriate for the trans-tendon repair have smaller diameters to avoid creating clinically pregnant tendon defects. The anchor diameter should be iii mm or less. The writer'due south preferred choice is the Trans-tend ballast (DePuy-Mitek, Raynham, MA) made with Biocryl Rapide. This preference is based on the proven osteoconductivity of the anchors' polymer, it is the only ballast system using a partially biodegradable suture, and the fact that the insertion cannula has a ridge which retracts the supraspinatus away from the greater tuberosity allowing improved visualization of the insertion site. This threaded biocomposite anchor comes with a single high strength suture. Two trans-tend anchors are inserted percutaneously through the tendon and into the greater tuberosity while viewing from the glenohumeral articulation (Figure 2). These anchors are placed at the anterior and posterior edges of the supraspinatus tear, aligned side-past-side, and inserted near the articular cartilage. Each anchor carries the two arms of the single suture through the supraspinatus tendon and into the bone (Effigy 3).

Figure 2 A Trans-tend anchor is inserted percutaneously through the tendon and into the prepared greater tuberosity while viewing from the posterior portal.

Figure three Here the two suture limbs from two Trans-tend anchors are seen passing from their insertion sites in the bone and upward through the supraspinatus tendon.

Having previously performed a subacromial synovectomy, these sutures are hands located in the bursa. One of the two suture artillery from each anchor is so retrieved through a working cannula, and then these two sutures are tied creating a mattress stitch spanning the 2 anchors. Once the second suture pair is tied with tension, these two completed mattress stitches shrink the tendon to the footprint. After both suture pairs are securely tied the repair is complete (Figure 4).

Figure 4 Once the two sutures are tied with tension, this creates a mattress sew together spanning the two anchors and compressing the tendon to the footprint. This is a bursal view of the repair from the posterior portal.

Other small diameter anchors, specially those designed for use in the glenoid can be used to perform the trans-tendon repair. The key point is that they should be small in bore and biodegradable or biocomposite if possible.

The release and repair approach requires completely detaching the remaining tendon fibers from the greater tuberosity and and then repairing the resulting tendon tear using a conventional technique. The anchors appropriate for this repair technique usually contain 2 or three sutures and are larger in diameter. They are more suitable for repairing the larger rotator cuff tendon tears than the glenoid type anchors used for the PASTA repair.

Monk's Hood tears

Monk'due south hood tears require a more ambitious approach than PASTA tears. Cordasco et al. treated both types of partial thickness tears with debridement and acromioplasty (6). They reported an overall failure charge per unit based upon the L'Insalata calibration of 29% (4 failures in xiv shoulders) in bursal-sided tears while only three% (2 failures in 63 shoulders) of the articular-sided tears failed. As with the PASTA tears, Monk'south Hood tears tin be repaired either by reattaching the torn portion to the footprint (in situ) or completing the tear by detaching the remnant cuff tissue and repairing it to the original footprint. The decision to select tear completion is based upon the status of the bursal tear tissue. If the torn tissue cannot exist readily mobilized, then tear completion will accomplish a more secure repair. Nonetheless, as more ordinarily occurs and as the authors adopt, reattaching the bursal tendon flap using triple loaded suture anchors creates what amounts to a double row repair maximizing footprint coverage.

The tear completion technique has the reward of removing the remaining cuff which provides better visualization of the footprint and tendon. Consequently the torn tissue tin can exist repaired using a familiar technique. A recent systematic review reported no long-term advantage of the trans-tendon repair over tear completion and repair with trans-tendon repairs reporting more hurting and stiffness in the early on post-operative catamenia (7). In contrast, as with the PASTA repair, the Monk's Hood in situ repair preserves the remaining cuff tissue and is technically more demanding.

Both trans-tendon and in situ Monk's Hood repairs provide greater construct forcefulness and, in our opinion, permit for a shorter postoperative immobilization menstruum. Mechanically the intact tendon fibers deed as an internal splint protecting the repaired tissue. This is specially true with the intact articular fibers which splint the bursal-sided repair. The in situ or PASTA repair restores the wide anatomic footprint with all the attendant benefits. As well the potential for a mismatch betwixt the tendon length and tendon tension is minimized considering the tissue was not excessively retracted in the first place. Consequently, this approach does non excessively lateralize the repair (7).

Smaller suture anchors (iv.5 mm diameter) are effective with Monk'due south Hood repairs. This is because the greater tuberosity is commonly non significantly osteoporotic and the smaller anchors volition provide adequate fixation for two or three sutures while minimizing the affect to the footprint bone.

Full thickness tears

Currently most approaches to the repair of full thickness rotator cuff tears tin be classified as either single-row or double-row. The best technique for a unmarried-row repair places the anchors next to the articular cartilage (minimizing the tension on the repaired tendon). The anchors should be triple-loaded and only simple sutures through the tendon tissue are needed. Finally, footprint perforations should be placed in the greater tuberosity lateral to the attached tendon to allow marrow elements to extravasate and create a neotendon adjacent to the healing tendon. These "marrow vents" create what has been called by Steve Snyder a "crimson duvet" (8,9). This has been shown to have a do good for cuff repair healing.

The minimum load required for a rotator cuff repair has not been clinically established and probably varies with os and rotator cuff tendon quality. A load level of 250 N was identified by Mazzocca et al. (10) and others (11). Nigh all recently introduced anchors designed to exist used for the rotator cuff repair provide this level of forcefulness. Backing upwardly a medial row with a lateral row to obtain sufficient strength is not necessary from a strength standpoint.

The current suture anchor trend is clearly toward radiolucent anchor materials. These materials include PEEK, biodegradable (poly levo lactic acid and poly dextro levo lactic acid), biocomposite polymers (containing beta-tricalcium phosphate or hydroxyapatite), and ultra high molecular weight polyethylene (UHMWPE) suture based anchors. The biocomposite anchors, especially those composed in role by β-TCP, offer the characteristic of osteoconductivity with bone ingrowth into the implant location. Withal, in that location is no published evidence demonstrating that this confers a clinical advantage.

Current double row repairs contain several concepts. I is the transosseous equivalent orientation of the sutures. This ways having the repair sutures aligned parallel to the tendon (orthogonal) to improve the biomechanics of the repair. Some other is suture bridging in which the sutures cantankerous i another when taken from their origin in the medial row to be inserted in a knotless lateral row anchor. Current clinically applicable biomechanical testing compares the triple-loaded single-row repair to the suture-bridging lateral-row repair (12).

The mechanical differences of these two repairs are important. Biomechanical data demonstrates that medial row anchors receive two-thirds of the full stress in a double row cuff construct. The suture-bridge lateral row receives only one-third of the stress. This has implications on the type of tendon failure that occurs as volition be addressed later. The medial row receives the stress first and consequently is beginning to fail. This can be contradistinct if the medial row sutures are non knotted creating a "pulley upshot".

The suture-bridging double-row technique uses knotless lateral anchors. A knotless lateral row ballast does not rely on a knot for security and must securely lock the suture in place.

When this type of construct fails it tends to do and so at the musculotendinous junction. Cho described two types of gage repair failures: Cho type 1 (failure at the footprint) and Cho type 2 (failure at the musculotendinous junction) (thirteen,14). Cho type 2 failures occur far more frequently with suture-bridging double-row repairs. Comparing the single-row to the suture-bridging double-row repair, Cho et al. reported that single-row repairs failed with a type ane failure in 74% and a blazon ii failure in 26%. In stark contrast suture-bridging double-row repairs failed by type 1 in only 26% and type two in 74% (P=0.049) (thirteen). In this written report the medial row for the repair was tied.

Single row

A unmarried-row repair with triple loaded anchors placed side by side to the articular cartilage takes into consideration the biomechanical superiority of constructs with three simple sutures over mattress stitches (15). Three simple stitches in triple-loaded anchors have also been demonstrated to show superior biomechanical behavior and lower re-tear rates compared to diverse double-row configurations (12). Placing these triple-loaded anchors medially adjacent to the articular cartilage instead of more laterally on the footprint minimizes repair tension while re-establishing a stiff footprint. The simple stitch should pass ideally 5 to 10 mm from the musculotendinous junction with a secure bite of nearly 10mm from the torn tendon edge (Figure v).

Effigy 5 The 3 different sutures from a single anchor are passed through the rotator cuff tendon. The three sutures from the ballast are noted to the right of this image and the paired ends creating simple stitches and a unmarried-row repair are seen passing through the tendon to the left. This is a view of the bursa from a posterior portal in a correct shoulder.

In older patients, poor tissue quality and tendon retraction are commonly found. Because of this tissue mobilization to cover the greater tuberosity is often not possible. Consequently, the unmarried-row rotator gage repair is the indicated technique for large and massive rotator cuff tears with lateral tendon loss and poor tendon mobility (Figure 6).

Figure vi Three simple stitches in triple-loaded anchors provide secure tendon fixation while minimizing tension on the repair. This view of the repair demonstrates the tied sutures with the blank footprint to the correct. Marrow vents in this footprint surface area can promote healing with a neotendon (bursal view from a posterior portal in a right shoulder).

Double row

Proponents of double row repair feel that double-row repairs are most effective for mid-size, large, and massive reparable rotator cuff tears. The anchor choice for these cases may depend on surgeon preference and patient specific requirements. For case, intraoperative tendon quality may influence the suture anchor choice considering the associated suture might be besides abrasive and result in tendon damage. It is important to consider the employ of suture record when selecting the best repair configuration.

Every bit with all rotator cuff tendon repairs, the start step is a careful assessment of the tear anatomy. The surgeon should spend time probing and manipulating the tendon to appraise its excursion and morphology. The proper mobilization of an "L-shaped" tear depends upon whether the "L" is anteriorly or posteriorly based. Non all tears are crescent shaped and some crescent shaped tears cannot achieve the articular cartilage margin of the footprint without mobilization procedures. A consummate assessment should identify where to put the anchors and pass their sutures. The success of a rotator cuff repair does not depend upon the number of anchors but on the anchor location and the suture-tendon configuration. The weakest link in whatever rotator gage tendon repair is at the suture-tendon interface.

A common pitfall in a double-row repair is the want to fully comprehend the anatomic footprint. It is piece of cake to over-tension the cuff particularly when the repair is performed with the arm in significant abduction. Sometimes the repair tin create a non-anatomic configuration especially in an attempt to increase footprint coverage. Over tensioning is peculiarly common with "L-shaped" tears that tin can begin to resemble "U-shaped" tears. "Fifty-shaped" tears should exist initially addressed with margin convergence (side-to-side sutures) to restore the normal anatomy. Sometimes all information technology takes is a single margin convergence run up to significantly alter the advent of the tear. This subsequently reduces the strain on the remaining tendon, decreases the tear size, and facilitates anatomic footprint restoration.

(I)

Medial anchors

For double row repairs, both medial and lateral rows require anchors. The medial row anchors are typically screw-in anchors containing at to the lowest degree two sutures. There are many anchors available for this task. Most of them are 5.5 or 6.5 mm in bore.

It is important to consider what anchor material will be best for each specific case. Poor os quality will accept an bear on. Some surgeons prefer metallic anchors for poor quality os. When using the dial for hole grooming the os density and its ability to agree an anchor can be assessed. If the punch penetrates the bone very hands, then a larger (6.5 mm diameter) ballast should be selected.

Smaller all-suture anchors are likewise bachelor for the medial row. In that location are several all-suture anchors on the market place. These all-suture anchors have many characteristics in common including a low profile and pocket-sized holes preserving the bone integrity in the footprint (Figure 7). They all are fabricated of UHMWPE suture woven through a length of suture tape. The ballast itself is created by applying traction to the suture. This traction draws the suture and tape sleeve confronting the cortical bone and compresses it into a ball which forms the anchor. The compressed anchor must be larger than the drill hole in the bone to permit the ballast to work. Since all-suture anchors base of operations their entire holding strength on the cortical os, the presence of osteoporotic bone below the cortex should not take a structural impact on anchor performance.

Figure 7 Smaller all-suture anchors are low contour with a small hole preserving the bone integrity in the footprint. This anchor is inserted side by side to the articular cartilage as a medial row ballast.

Several different all-suture anchors are bachelor (xvi,17). It is noteworthy that 1 all-suture ballast ball (Q-Fix, Smith & Nephew, Andover, MA) is created using a mechanical tightening device rather than surgeon traction on the suture (18). This mechanical inserter creates a considerably stronger ballast construct and in homo shoulder specimens showed less cyclic deportation and greater forcefulness than the other all-suture anchors (18).

While all-suture anchors tin access hard to attain areas, and the smaller drill hole allows the placement of more anchors than larger conventional anchors in the same area, these advantages do not seem relevant to the greater tuberosity footprint. Additionally the insertion drills associated with all-suture anchors measure between xx and 24 mm in length. While this drill length tin can be very problematic in the glenoid location, the greater tuberosity should non be an issue. In fact, concerns be that the loss of the required cortical integrity at the greater tuberosity footprint caused by preparing a suitable bone bed for tendon reattachment may compromise all-suture anchor stability. Furthermore, no objective data currently exists to indicate that multiple fixation points improve repair biomechanics or clinical functioning.

When using all-suture anchors, a punch to create the ballast hole is safer than drilling due to the risk of associated tissue trauma and damage to the cortical bone. All-suture anchors need good cortical os for fixation and a punch compacting the next bone may reinforce the insertion site rather than removing bone with a drill. In the greater tuberosity it may too be better to accelerate the all-suture anchor deeper into the subcortical bone to allow acceptable room for ballast expansion in the bone bed giving the anchor better subcortical fixation.

(2)

Lateral rows anchors

Lateral row anchors in the suture-bridging double-row technique are of necessity knotless anchors. These are inserted into the bone of the lateral greater tuberosity using an orthogonal (correct bending) approach. The anchor can be either self-punching, require predrilling, or punching followed by tapping. Conspicuously the self-punching anchors hold a technical advantage over the other types since they can be inserted in a single step. They do not create the significant technical claiming of first creating the recipient pigsty so finding that pigsty over again to insert the anchor.

Lateral-row knotless anchors are frequently made using non-absorbable materials. This is because the self-punching function requires a hard, shatter proof material to penetrate the bone and create the pathway for the rest of the ballast. A suture passing basket threaded through the inserter'due south finish for the lateral-row anchor allows threading of the medial row sutures. Typically four No. 2 sized sutures tin be held in a single lateral anchor.

Knot tying of the medial row is not essential for a good double-row repair. One preferred technique uses two bioabsorbable iv.75 mm SwiveLock anchors (Arthrex, Naples, FL) for the medial row threaded with suture tape placed at the articular cartilage edge spaced at least 1.5 cm apart. The lateral row created by additional four.75 mm SwiveLock anchors is located at the lateral side of the greater tuberosity. Linking two strands of record (one from each medial anchor) creates a suture-bridging design (Figure viii). Medial knots are not needed in the record.

Figure viii Suture-bridging anchor in the lateral greater tuberosity secures the medial row sutures laterally without the need for knots.

A second choice that creates a similar configuration uses double-loaded Y-Knot (Linvatec, Largo, FL) all-suture anchors for the medial row at the articular border also spaced at least 1.5 cm apart. The sutures are secured medially with sliding knots fixing the tendon to the bone while the lateral row is secured with 4.5 mm PEEK PopLok (Linvatec, Largo, FL) anchors in a suture-bridging pattern.

For smaller tears and to reduce the number of anchors used, a "parachute ballast" technique provides an option (Figure 9). Tears less than three cm in AP length tin be repaired by securing the tendon medially with ii double-loaded suture anchors. The 4 suture pairs are then tied medially and the suture tails passed across the remaining tendon and into one lateral knotless ballast. The anchors selected may be the aforementioned equally used for the speed fix pattern. For the medial row, metallic anchors may besides be considered.

Figure ix A parachute repair uses 4 suture pairs from 2 medial row anchors that are tied medially with the suture tails passed across the remaining tendon into one lateral row knotless anchor.

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Suture selection

The introduction of UHMWPE-containing sutures changed the standard for suture forcefulness and performance peculiarly in rotator cuff repairs. Suture breakage is now normally due to poor surgical technique such as partially cutting, clamping, or abrading the suture. This weakens even UHMWPE sutures and tin can result in suture breakage during knot tying or cycling of the suture through an anchor. If the suture is damaged close to the anchor, the surgeon tin can adjust the suture arm lengths to avoid stressing the damaged department. A non-sliding knot is preferred in that state of affairs.

Less annoying sutures will avoid tissue damage. FiberWire is currently the most abrasive of the UHMWPE containing sutures. Kowalsky et al. (nineteen) compared FiberWire to monofilament polypropylene and braided polyester sutures. While these sutures demonstrated different strengths and constructions, the smooth monofilament polypropylene was the to the lowest degree abrasive. Interestingly, FiberWire demonstrated less abrasiveness in human infraspinatus tendon than the classic braided polyester suture. Deranlot et al. (20) compared FiberWire, FiberTape, OrthoCord and ForceFiber in sheep infraspinatus tendons and noted increased abrasive effects with FiberWire and FiberTape. Lambrechts et al. (21) compared FiberWire, OrthoCord, and Ethibond in human supraspinatus and infraspinatus tendons and found that FiberWire was significantly more abrasive than OrthoCord. Williams et al. (22) evaluated 9 different sutures in a sheep infraspinatus and likewise noted the highest abrasive effect was with FiberWire suture. Ono et al. (23) evaluated FiberWire, FiberTape, UltraBraid, and UltraTape sutures in sheep infraspinatus tendons. These record sutures performed better than their corresponding sutures with less displacement and less suture hole enlargement in all specimens.

DynaCord

Rotator cuff tendon repairs can fail for many reasons including the lack of consequent tendon approximation to os, knot slippage, and suture loosening during the healing period. Creep is the viscoelastic tendency for any cloth such as a suture to deform permanently under persistent stress. Creep affects suture material also and results in some degree of suture loosening after the knot tying is completed. Suture loosening with suture-bridging double-row repairs can bear upon the area and force per unit area of tendon-bone contact (24).

DynaCord (DePuy-Mitek, Raynham, MA) is a suture composed of an internal silicone/NaCl core surrounded by a braided UHMWPE and can address this creep. This suture slowly shortens after knot tying in an aqueous environment and clinically offers the potential to maintain tissue approximation and knot security in the postal service-operative period. DynaCord appears to be less annoying than other sutures. Owens et al. (24) reported that in an ovine rotator gage model, there was less tendon cut-through demonstrated with DynaCord suture than FiberWire suture. In addition, 2 of the FiberWire specimens showed complete tendon cut-through. Because of the contempo introduction of DynaCord suture, no published clinical outcomes are bachelor.

Any concerns near the use of silicone in a suture cloth were partly addressed by a contempo report which showed that DynaCord silicone particles released during mechanical suture rupture did not migrate to adjacent lymph nodes (25).

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Summary

Rotator cuff suture anchors are larger, withstand higher cyclic loads, and hold more than sutures than smaller glenohumeral anchors. They provide secure fixation in the osteoporotic os often found in the greater tuberosity. Bioabsorbable, biocomposite, and PEEK anchors have largely replaced metal anchors. The biodegradable anchors provide both strength and durability and facilitate postoperative imaging and revision surgery. The suture anchor secures the rotator cuff tendon to the greater tuberosity until biologic healing at the tendon-bone interface occurs. Suture anchors have a learning curve. Familiarization with the specific anchor and its associated equipment before entering the surgical suite is essential to adequately mastering its use. Selecting an appropriate biodegradable ballast will solve issues related to postoperative imaging and retained strange fabric.

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Acknowledgments

Funding: None.

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Provenance and Peer Review: This article was commissioned by the Guest Editor (Adnan Saithna) for the serial "Electric current and Emerging Concepts in the Management of Rotator Cuff Tears" published in Annals of Joint. The commodity has undergone external peer review.

Conflicts of Interest: Both authors have completed the ICMJE uniform disclosure form (bachelor at http://dx.doi.org/ten.21037/aoj-20-32). The serial "Electric current and Emerging Concepts in the Management of Rotator Cuff Tears" was commissioned by the editorial office without any funding or sponsorship. AFCA reports personal fees from ConMed, outside the submitted work. FAB reports grants, personal fees and other from DePuy-Mitek, outside the submitted work. In addition, FAB has a patent DePuy-Mitek with royalties paid. The authors have no other conflicts of interest to declare.

Upstanding Argument: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any office of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access commodity distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs four.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/past-nc-nd/4.0/.

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doi: 10.21037/aoj-20-32
Cite this commodity as: Cobaleda Aristizabal AF, Barber FA. Rotator gage repair: technical considerations influencing optimum anchor option in rotator cuff repair. Ann Joint 2021;6:18.

How Many Anchors Are Used In Rotator Cuff Surgery,

Source: https://aoj.amegroups.com/article/view/5914/html

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